Service profiling and outcomes benchmarking using the CORE-OM: toward practice-based evidence in the psychological therapies. Clinical Outcomes in Routine Evaluation-Outcome Measures

To complement the evidence-based practice paradigm, the authors argued for a core outcome measure to provide practice-based evidence for the psychological therapies. Utility requires instruments that are acceptable scientifically, as well as to service users, and a coordinated implementation of the measure at a national level. The development of the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) is summarized. Data are presented across 39 secondary-care services (n = 2,710) and within an intensively evaluated single service (n = 1,455). Results suggest that the CORE-OM is a valid and reliable measure for multiple settings and is acceptable to users and clinicians as well as policy makers. Baseline data levels of patient presenting problem severity, including risk, are reported in addition to outcome benchmarks that use the concept of reliable and clinically significant change. Basic quality improvement in outcomes for a single service is considered.

Angiotensin-converting enzyme inhibitors in adults after the Mustard procedure

Angiotensin-converting enzyme inhibitors had no significant effect on cardiopulmonary exercise function in 14 patients who had undergone a Mustard operation for transposition of the great arteries. In some patients aerobic capacity improved and maximum systolic blood pressure decreased.

Noncompaction of the myocardium associated with Roifman syndrome

Noncompaction of the ventricular myocardium, sometimes referred to as "spongy myocardium", appears as excessive and prominent trabeculations and deep intratrabecular recesses within the ventricular wall, usually involving the left ventricle, although the right ventricle and interventricular septum can also be affected. It may occur with or without additional heart malformations. Roifman syndrome is a constellation of antibody deficiency, spondyloepiphyseal dysplasia, facial dysmorphism, growth retardation, and retinal dystrophy. We report a patient with Roifman syndrome who presented with noncompaction of the left ventricular myocardium. Our findings expand the spectrum of diseases associated with noncompaction. The recognition of noncompaction among patients with Roifman syndrome is important, as the immune deficiencies may be subtle and undiagnosed until adulthood. Thus, some patients may first present with cardiac failure.

Effects of endothelin-1 on resuscitation rate during cardiac arrest

OBJECTIVES

Endothelin-1 (ET-1) is a potent peripheral and coronary artery vasoconstrictor and has been shown to improve coronary perfusion pressure (CPP) during cardiac arrest. The effect of ET-1 on return of spontaneous circulation (ROSC) following cardiac arrest has not been studied. Our hypothesis was that ET-1 does not improve ROSC from cardiac arrest when compared to placebo.

METHODS

A total of 11 immature swine were used in this laboratory study. Animals were randomized to receive 300 microg ET-1 and standard dose epinephrine (SDE) or placebo and SDE during arrest. After a 10-min period of no-flow ventricular fibrillation (VF), CPR was performed for 3 min followed by ET-1/SDE or placebo/SDE administration. Following drug administration, standard ACLS was followed with SDE given every 3 min. Aortic pressure was monitored during resuscitation. ROSC was defined as any perfusing rhythm with a systolic pressure greater than 60 mmHg for 60 s. Animals received post-ROSC care as needed for 2 h post-ROSC. CPP and ROSC were analyzed using repeated measures ANOVA and Fischer's exact test respectively. P<0.05 was considered significant.

RESULTS

Pre-arrest variables and CPP prior to ET-1 administration were not different between groups. Following ET-1 administration, CPP was significantly increased at all time points in ET-1/SDE versus placebo/SDE animals. ROSC was achieved in 1/5 (20%) ET-1/SDE versus 1/6 (16.7%) placebo/SDE animals (P>0.05). The resuscitated ET-1/SDE animal survived 6.5 min compared to 120 min for the resuscitated placebo/SDE animal.

CONCLUSIONS

In our study, ET-1 administration during cardiac arrest increases CPP but does not improve ROSC.

Prospective CYP2D6 genotyping as an exclusion criterion for enrollment of a phase III clinical trial

A phase III study was performed to compare the efficacy and safety of lamotrigine (Lamictal), desipramine (Norpramin), and placebo in the treatment of unipolar depression. Desipramine is extensively metabolized by cytochrome P450 2D6 (CYP2D6), and kinetics of this compound are altered in poor metabolizers. Genotyping was utilized to exclude poor metabolizers in order to increase subject safety and to eliminate the need to continuously monitor plasma desipramine levels. As part of screening, subjects were genotyped for the *3(A), *4(B), and *5(D) alleles, which identify approximately 95% of poor metabolizers. Extensive metabolizers were eligible for randomization to the lamotrigine, desipramine, or placebo arm. Follow-up genotyping for the *6(T) and *7(E) alleles was performed after study enrollment and was used to identify poor metabolizers who may have been incorrectly identified as extensive metabolizers upon initial three-allele screening. Of 628 subjects screened for *3(A), *4(B), *5(D) alleles, 590 (93.9%) were classified as extensive metabolizers. The remaining 38 (6.1%) subjects were poor metabolizers and excluded. Subsequent *6(T) and *7(E) testing revealed that two poor metabolizers had been enrolled, and the follow-up genotyping provided an explanation for the high desipramine plasma concentrations in one subject. No differences in phenotypic or allelic frequencies were found between the study population and literature populations. However, the frequency of poor metabolizers varied among clinical sites (0-15%). For a compound that is extensively metabolized by CYP2D6, prescreening subjects for *3(A), *4(B), *5(D), *6(T) and *7(E) alleles can increase subject safety and eliminate the need to continuously monitor drug plasma concentrations.

Cyclosporine A neurotoxicity in a patient with idiopathic renal magnesium wasting

We report a female child who had idiopathic renal magnesium wasting secondary to suspected Gitleman syndrome and cyclosporine A neurotoxicity after a heart transplant. The child had acute, progressive encephalopathy, intractable seizures, quadriparesis, and extensive, bilateral cortical involvement on neuroimaging. Two days after discontinuation of the cyclosporine, the child's condition improved dramatically, including an improved level of consciousness, and she became seizure free. By 6 weeks, she was fully ambulatory. Follow-up magnetic resonance imaging and electroencephalograms demonstrated significant improvement. This patient had drug-induced neurotoxicity, exacerbated by hypomagnesemia. Cyclosporine should be used cautiously in transplant patients with Gitelman syndrome or other acquired magnesium homeostasis disorders because of the possible increased risk of neurotoxicity. This report is the first case of a patient with both cyclosporine neurotoxicity and magnesium-wasting nephropathy.

Advances in the treatment of hepatitis C: combination antiviral therapy with interferon alfa-2b and ribavirin

PURPOSE

To provide nurse practitioners with the information to manage patients with chronic hepatitis C (HCV) receiving a new combination drug therapy containing ribavirin and interferon alfa-2b.

DATA SOURCES

Reviews of clinical trial results including large multicenter trials, Centers for Disease Control and Prevention documents, data from the drug manufacturer.

CONCLUSION

This new therapy offers the potential for HCV remission or complete cure of the HCV infection. Although virologic responses are markedly improved with combination therapy, the side effects associated with combination therapy warrant regular patient monitoring, management, and medical intervention when clinically indicated.

IMPLICATIONS FOR PRACTICE

Combination therapy does not significantly worsen the side effects associated with mono-therapy, which are predictable, manageable, and reversible. However, proper patient education, symptom management, vigilance for serious side effects, and monitoring of hematologic parameters are critical to patient outcome.

Transcatheter closure of atrial septal defects using the Cardio-Seal implant

OBJECTIVE

To review the outcomes of transcatheter closure of atrial septal defects using the Cardio-Seal implant.

DESIGN

A prospective interventional study.

SETTING

Tertiary referral centre.

PATIENTS

The first 50 patients (median age 9.7 years) who underwent attempted percutaneous occlusion.

INTERVENTIONS

Procedures were done under general anaesthesia and transoesophageal guidance between December 1996 and July 1998.

MAIN OUTCOME MEASURES

Success of deployment, complications, and assessment of right ventricular end diastolic diameter, septal wall motion, and occlusion status by echocardiography.

RESULTS

The median balloon stretched diameter was 14 mm. Multiple atrial septal defects were present in 11 patients (22%) and a deficient atrial rim (< 4 mm) in 19 (38%). In four patients (8%), a second device was implanted after removal of an initially malpositioned first implant. There were no significant immediate complications. All patients except one were discharged within 24 hours. At the latest follow up (mean 9.9 months) a small shunt was present in 23 patients (46%), although right ventricular end diastolic dimensions (mean (SD)) corrected for age decreased from 137 (29)% to 105 (17)% of normal, and septal motion abnormalities normalised in all but one patient. No predictors for a residual shunt were identified. Supporting arm fractures were detected in seven patients (14%) and protrusion of one arm through the defect in 16 (32%), the latter being more common in those with smaller anterosuperior rims. No untoward effects resulted from arm fractures or protrusion. There were no complications during follow up, although five patients (10%) experienced transient headaches.

CONCLUSIONS

The implantation of the Cardio-Seal device corrects the haemodynamic disturbances secondary to the right ventricular volume overload, with good early outcome.

Repopulation of rho0 cells with mitochondria from a patient with a mitochondrial DNA point mutation in tRNA(Gly) results in respiratory chain dysfunction

Familial hypertrophic ventricular cardiomyopathy has been demonstrated to be associated with a number of mitochondrial DNA (mtDNA) mutations. A fibroblast cell line carrying a mutation in its mtDNA at position 9997 in the gene encoding tRNA glycine was obtained from a patient with hypertrophic cardiomyopathy. To demonstrate that the etiology of this disease was a result of the mtDNA mutation, cybrid clones were constructed by fusion of enucleated patient skin fibroblasts to rho0 osteosarcoma cells. Clones carrying high levels of mutant mtDNA showed predominantly cytochrome c oxidase and complex I deficiency, as well as an elevated lactate/pyruvate (L/P) ratio, a biochemical marker characteristic of respiratory chain deficiencies. Pulse-labeling experiments demonstrated a strong negative correlation between the levels of newly synthesized mtDNA-encoded polypeptides and glycine content. These data suggest that the T9997C mutation in mtDNA is causative of respiratory chain dysfunction when present at high levels of heteroplasmy.

Combination Interferon alfa-2b/ribavirin therapy for the treatment of hepatitis C: nursing implications

An effective new therapeutic option consisting of Intron A (Interferon alfa-2b, recombinant; Schering Corporation, Kenilworth, NJ) Injection and Rebetol (Ribavirin, USP) Capsules is now available for the initial therapy of patients with hepatitis C and for patients who had previously responded to alpha interferon but subsequently relapsed. The combination of recombinant interferon alfa-2b/ribavirin therapy increases hepatitis C viral clearance 10-fold in hepatitis C relapse patients and almost threefold in previously untreated patients compared with alpha interferon monotherapy. There is no synergistic toxicity apparent with the two-drug combination. Ribavirin does not significantly worsen the side effects associated with interferon alfa-2b, which are predictable, manageable, and reversible. The major side effects of combination therapy include flulike symptoms, neutropenia, psychiatric disorders, and anemia; however, these side effects are well known and can be managed with dose modifications and nursing intervention. The assistance of nurses in patient education, in side effect management, in hematologic parameter monitoring, and in medication dosing and administration is crucial to maximizing patient compliance and therapy outcome.

Extended aortic root replacement with aortic allografts or pulmonary autografts in children

OBJECTIVES

To evaluate the early results and effectiveness of left ventricular outflow tract enlargement with aortic allograft or pulmonary autograft in children with complex left ventricular outflow tract obstruction.

METHOD

The records of 30 children who underwent aortic root enlargement and replacement with either an aortic allograft (22 patients) or pulmonary autograft (8 patients) between January 1987 and June 1997 were reviewed. The predominant diagnosis was complex left ventricular outflow tract obstruction (n = 19), associated with aortic incompetence in 11 children. Before root enlargement, 27 children underwent surgical valvotomy (14 patients), balloon dilatation (10 patients), or both interventions (3 patients). Mean age at root enlargement was 5.4 +/- 3.5 years (range, 2 days-16 years). Most of the children (27 patients) underwent a Konno aortoventriculoplasty. Concomitant septal myectomy was performed in 4 children, mitral valve procedure in 5 children, and endocardial fibroelastosis resection in 1 child.

RESULTS

Five children (17%) died in hospital. Four of these were infants less than 2 months old. All had acute aortic incompetence as the result of recent intervention necessitating urgent operation. The fifth child, aged 10 years, died of myocardial failure 2 weeks after the operation. During the follow-up period (mean length, 4.1 +/- 2.8 years), sudden death occurred in 1 child 3 months after the operation. Follow-up echocardiograms (obtained for 23 of the surviving 24 children within 3 +/- 2.3 years) showed a left ventricular outflow tract gradient reduced from a mean of 65 to 11 mm Hg (P =.001); Z value increased from a mean of -0.5 to 4.1 (P <. 001), and aortic incompetence was trivial or mild except in 2 children.

CONCLUSION

Urgent aortic root enlargement in decompensating neonates carries higher mortality rates. In older children, the early results of root enlargement and implantation of allograft or autograft are good.

Testing the Compatibility Test: How Instructions, Accountability, and Anticipated Regret Affect Prechoice Screening of Options

Subjects screened a set of jobs, retaining those for which they wished to apply and rejecting those that were no longer under consideration. In Experiment 1, subjects who indicated the jobs for which they would apply/not apply screened out fewer jobs than those with instructions to reject/not reject or those with instructions simply to screen (control). There were no differences between the reject and control conditions. Experiment 2 used a design similar to that of Experiment 1, but subjects were made accountable for their screening judgments. The reject-apply discrepancy remained, but the accountability manipulation made the subjects more stringent in their screening compared to those who were not accountable for their judgments. In Experiment 3, subjects were told to consider either the regret resulting from retaining a bad option (regret bad) or the regret from rejecting a good option (regret good). Subjects in the regret bad condition rejected more jobs than did subjects in the regret good condition, but not more than subjects in the control condition. As predicted by image theory, the normal screening process appears to be to screen out the bad options rather than screen in the good options. This is demonstrated by screening in the control condition being similar to screening under the reject instructions (Experiment 1) and under regret bad instructions (Experiment 3), since these conditions were shown to focus attention on the bad options. Copyright 1999 Academic Press.

A Rejection Threshold in Justice Evaluations: Effects on Judgment and Decision-Making

This research examined the process through which justice evaluations are formed. Using image theory's screening process we hypothesized that a rejection threshold exists with regard to violations of just treatment (e.g., laying off an employee without notice). If the number of violations exceeds the decision-maker's threshold, a negative justice evaluation results. Nonviolations (e.g., providing laid-off employees with a generous severance package) were hypothesized to only influence justice evaluations when violations do not exceed the threshold. Three studies compared the impact of justice violations and nonviolations on fairness evaluations. We also examined differences in fairness evaluations operationalized as judgments vs decisions. Results indicated that when making judgments about fairness, both violations and nonviolations are equally important. However, when one has to decide on a course of action based on considerations of fairness, nonviolations are only considered if fewer than three violations have been encountered. These results identify important distinctions between judgment and decisions and have implication for research examining outcomes of justice evaluations. Copyright 1998 Academic Press.

Low temperature aqueous electrospray ionization mass spectrometry of noncovalent complexes

In the present study we describe conditions that permit the characterization of noncovalent protein-substrate complexes in aqueous solution by microspray electrospray ionization-mass spectrometry (ESI-MS), using a heated transfer capillary at low temperature (45 degrees C). Specifically, we examined the binding of calmodulin to two polypeptides; the calmodulin-binding domain of calmodulin-dependent protein kinase II (CamK-II) and melittin. Calmodulin, a well known calcium-binding protein, binds to a number of small amphipathic peptides in a calcium-dependent manner. Our results directly show that both peptides form equimolar complexes with calmodulin only in the presence of calcium. The stoichiometry necessary for the formation of each complex was 1:1:4 for calmodulin:peptide (melittin or CamK-II):Ca2+, respectively. Furthermore, it is demonstrated that the detection of the complex in ESI-MS is source temperature dependent.

Hypersensitivity myocarditis caused by an allergic reaction to cefaclor

An adolescent girl was seen with acute heart failure 6 days after the onset of a viral illness and otitis media treated with cefaclor. An endomyocardial biopsy specimen revealed active myocarditis with an eosinophilic infiltrate typical of hypersensitivity myocarditis. The patient showed dramatic improvement within 48 hours after withdrawal of the drug and administration of corticosteroids and immunoglobulin.

A phase I trial and pharmacokinetic evaluation of CI-980 in patients with advanced solid tumors

CI-980 is a synthetic mitotic inhibitor that binds to the colchicine binding site of tubulin. It demonstrates broad activity against human and murine tumor models and shows no cross resistance with tumor models whose mechanism of resistance is mediated by P-glycoprotein (MDR-1). A phase I study was completed in 25 patients with solid tumors using a 24-hour infusion schedule, with courses repeated every 3 weeks. Eight dose levels were tested between 1.2 and 15.6 mg/m2. The maximum tolerated dose was 14.4 mg/m2. Neutropenia was dose-related but not dose-limiting; thrombocytopenia was infrequent. CNS toxicities were dose-limiting and consisted of dizziness, headache, loss of coordination, loss of consciousness, nervousness, and other symptoms. These events occurred near the end of the infusion and were reversible, usually within 24 hours. One patient who was to be treated at dose level 8 (intended dose was 19.2 mg/m2; actual dose was 15.6 mg/m2) became encephalopathic prior to completion of the infusion. Other adverse events included gastrointestinal toxicities (nausea, vomiting, anorexia, constipation, stomatitis, dyspepsia, bleeding, cheilitis), IV site erythema, fever, and fatigue. A partial response was observed in one patient with colon cancer and reductions in CA-125 levels were observed in 2 patients with ovarian cancer. Pharmacokinetics were linear and dose-proportional. Results indicate high systemic clearance and wide tissue distribution. Mean pharmacokinetic parameter values: T1/2 = 5.52 hours, plasma clearance 1163 mL/min/m2, and Vdss 376 L/m2.

Complication of ventricular demand pacing after orthotopic heart transplantation: unusual case of pacemaker syndrome in an infant

BACKGROUND

Sinus node dysfunction is the most common indication for antibradycardiac permanent pacing after heart transplantation. Lack of atrioventricular synchrony during pacing can result in symptoms ranging from mild chest discomfort to severe manifestations such as dyspnea, hypotension, and cardiovascular collapse, all of which are ascribed to pacemaker syndrome. In infants pacemaker syndrome is often only recognized in the face of marked hemodynamic compromise.

RESULTS

This report details an unusual account of pacemaker syndrome in an infant after orthotopic heart transplantation.

CONCLUSIONS

Careful assessment of atrioventricular synchrony is important after infant transplantation.

Supramitral valve obstruction from hypertrophied native atrial tissue as a complication of orthotopic heart transplantation

An acquired form of cor triatriatum, resulting in significant supramitral valve obstruction, complicating a pediatric orthotopic heart transplantation was diagnosed by transesophageal echocardiography. Surgical resection of the hypertrophied atrial septum and atrial wall corrected the anatomic obstruction and improved the hemodynamics.

Balloon angioplasty of recurrent coarctation: a 12-year review

OBJECTIVES

This study was undertaken to investigate the long-term outcome of balloon angioplasty for recurrent coarctation of the aorta in a large series of patients.

BACKGROUND

Balloon angioplasty has become the standard treatment for residual or recurrent aortic coarctation. Despite the widespread use of this treatment modality, there are few data outlining the long-term outcome of a large patient cohort.

METHODS

Clinical, echocardiographic, hemodynamic and angiographic data on 90 consecutive patients who underwent balloon angioplasty between January 1984 and January 1996 were reviewed.

RESULTS

Mean systolic pressure gradients were reduced from 31 +/- 21 to 8 +/- 9 mm Hg after dilation (p = 0.0001). The mean diameter of the stenotic site, measured in the frontal and lateral views, increased by 38% and 35%, respectively (p = 0.001). Neurologic events occurred in two patients, with one death. An aortic tear occurred in one patient, requiring surgical intervention. Optimal results were defined as a postprocedure gradient < 20 mm Hg and were obtained acutely in 88% of patients. At long-term follow-up (12 years), 53 (72%) of 74 patients with an early optimal result remained free from reintervention. Transverse arch hypoplasia, defined as an arch dimension < 2 SD below the mean for age, was the primary predictor of the need for reintervention.

CONCLUSIONS

Although the majority of patients undergoing percutaneous balloon angioplasty for recoarctation of the aorta will achieve long-term benefit, the need for further surgical intervention in those with transverse arch hypoplasia remains high.

HMO partnering: the provider dilemma

While the growth of HMOs has slowed patient visits to doctors, it also has created a deluge of press clippings. On July 16, 1996, three articles on the subject appeared in the Wall Street Journal, front section. The headlines painted a vivid picture of the forces acting on HMOs and providers alike (Figure 1). The articles portended more change for healthcare. The "shake-out," a term applied to industries in serious transformation, brings shedding of excess capacity and loss of jobs and income. Providers, in particular, find themselves in a difficult dilemma. They must not only cut costs as reimbursement drops, but also retain patients with good outcomes and high quality service. Patient retention means keeping the individual patient from switching to another provider and keeping the insurer's group of patients as an authorized provider for that insurer. The relationship between provider and HMO lies at the heart of the provider dilemma. The HMO structure, which shifts financial risk for care, is quickly setting the standard, for healthcare pricing, medical standards, and management practices. Understanding and responding to HMO needs are vital to competitive advantage and survival. The article discusses the inherent dilemma of HMO and provider partnering and suggests provider responses.

Natural history of Alström syndrome in early childhood: onset with dilated cardiomyopathy

Alström syndrome is an autosomal recessive disorder characterized by cone-rod dystrophy, obesity, hearing impairment, and diabetes caused by insulin resistance. By reviewing the charts of eight patients followed for periods of 2 to 22 years, we established the natural history of this syndrome during childhood. Five patients, in four families, were seen between the ages of 3 weeks and 4 months with a dilated cardiomyopathy, a previously unrecognized feature of the syndrome. Photophobia and nystagmus were first documented in the eight patients between the ages of 5 months and 15 months. In all patients, electroretinography initially showed a severe cone impairment with mild (2/8) or no (6/8) rod involvement. Electroretinograms, obtained again at ages 9 to 22 years for four patients, revealed extinguished rod-and-cone responses. Obesity developed during childhood in seven patients, in at least three of them before age 2 years. Hearing impairment (5/8) and diabetes/glucose intolerance (4/8) were diagnosed at the end of the first decade or during the second decade. This constellation of features should facilitate early diagnosis of the syndrome.

An additional mitochondrial tRNA(Ile) point mutation (A-to-G at nucleotide 4295) causing hypertrophic cardiomyopathy

A third point mutation in the mitochondrial tRNA(Ile) gene associated with hypertrophic cardiomyopathy and respiratory chain dysfunction in heart is reported. An A-to-G transition at nucleotide position 4295 was shown to be highly evolutionarily conserved, never present in control individuals, and to segregate with the disease. A PCR-based diagnostic test and endomyocardial biopsies were used to detect both the biochemical deficiency and the level of heteroplasmy in heart. The implications of this new mitochondrial DNA point mutation are discussed.

Nurses' perceptions of their role and role conflicts

Nurses' perceptions of their professional role and their experience of role conflict were explored in a sample of certified general rehabilitation nurses. Nonnurse healthcare professionals who are on the same teams as the participating nurses also were assessed for their expectations of the nurse's role. The level of locus of control was identified among the various professions. The major finding of the study was that the rehabilitation nurses shared a consistent view of their professional role and of how they believed other professionals saw this role. The results showed that the nonnurse professionals were to some extent unaware of the expectations that the nurses held for the nursing role. There was no appreciable difference in the level of locus of control among team members, a situation which may have a leveling effect on the team dynamics. These findings have implications for professional role clarity, the promotion of locus of control, and interdisciplinary team dynamics.

Cardiac dysfunction late after cardiotoxic therapy for childhood cancer

Despite a wealth of data documenting acute cardiac injury from anthracycline therapy and/or mediastinal radiotherapy used for childhood cancer, little information is available on the long-term consequence of these insults. Twenty-nine patients (mean age 15 +/- 4.3 years) from The Late Effects Follow-Up Clinic For Childhood Cancer study, who had been in continuous, complete remission and off chemotherapy for a minimum of 2 years (mean follow-up 7.2 +/- 3.2) were studied. All patients had normal ejection fractions before and during cancer therapy and all were in New York Heart Association class I at the time of study. Systolic and diastolic functions were assessed by 2-dimensional echocardiography, Doppler flow velocity, and radionuclide angiography, and results were compared with normal control subjects. Left ventricular mass and mass index were significantly reduced in the patient population. Fractional shortening was decreased overall and end-systolic wall stress was much higher in patients than in controls. However, contractility, as assessed by the relation of wall stress to rate-corrected velocity of shortening, was decreased by > or = 2 SDs in only 6 of 28 patients, and the force-mass relation was actually increased in the patient group as a whole. Mitral valve inflow velocities were significantly increased but the pattern was abnormal. These results suggest a pattern consistent with a thin-walled, complaint left ventricle with reduced muscle mass performing under above-normal levels of wall stress. Contractility measurements were normal or increased in the group, but some patients clearly demonstrated development of reduced contractile function.(ABSTRACT TRUNCATED AT 250 WORDS)

Maternally inherited hypertrophic cardiomyopathy due to a novel T-to-C transition at nucleotide 9997 in the mitochondrial tRNA(glycine) gene

We report a unique heteroplasmic T-to-C transition at nucleotide 9997 in the mitochondrial tRNA(glycine) gene in a multiplex family who manifested nonobstructive cardiomyopathy. The degree of mtDNA heteroplasmy generally correlated with the severity of the symptoms. This T-to-C transition disrupts hydrogen bonding in the region adjacent to the acceptor stem of the tRNA molecule. The thymine residue at position 9997 is highly conserved in mammals, as well as in various vertebrates and invertebrates. A PCR diagnostic test for the presence of the 9997 T-to-C transition revealed that the base change was always present in high proportion in affected family members, not present in unaffected family members, and never present in control subjects from various ethnic groups (25 groups sampled, 42 individuals), thus ruling out the possibility that this change represents a polymorphic variant in the general population. The degree of heteroplasmy in lymphoblast cultures also correlated with the level of enzyme activity present for cytochrome c oxidase (complex IV) and succinate cytochrome c oxidoreductase (complexes II and III). The absence of previously reported mtDNA mutations associated with hypertrophic cardiomyopathy was verified by both PCR diagnostic procedures and sequence analysis. All mitochondrial tRNA genes, as well as genes encoding ATPase subunits 6 and 8, were sequenced and found not to possess base changes consistent with the clinical profile. More detailed biochemical and molecular biological investigations are discussed.

Polyethylene glycolated interleukin-2 as maintenance therapy for acute myelogenous leukemia in second remission

Seven patients in second complete remission of acute myeloid leukemia (AML) aged 19-65 years were treated with polyethylene glycolated interleukin-2 (PEG IL-2), 1 x 10(6) U/M2 IV weekly as the sole postremission therapy. Second remission duration was in the range of 4-49+ months, and three patients had a second remission duration substantially longer than their first (6, 21+, and 42+ months). The results suggest that PEG IL-2 may prolong second remission duration in AML and that a prospective randomized study designed to test that idea is warranted.

Heparin therapy in pediatric patients: a prospective cohort study

Current guidelines for heparin therapy in pediatric patients have been extrapolated from trials in adult patients without rigorous evaluation of efficacy and safety. We prospectively monitored consecutive pediatric patients receiving systemic doses of heparin over 10 mo at one institution using a predetermined nomogram to monitor maintenance therapy. Sixty-five consecutive children; 38 males and 27 females, received systemic doses of heparin. Thirty children had deep venous thrombosis and/or pulmonary embolism; 11 had arterial thrombi, most frequently after diagnostic angiography; and the remaining 24 received heparin prophylactically, for congenital heart disease. Twenty-nine (45%) of the 65 patients were less than 1 y of age and 22 (34%) were 10 y or older. Congenital heart disease was the predominant diagnosis under 1 y and deep venous thrombosis in older children. After a bolus dose of 50 U/kg, 39% of children (n = 30) achieved a minimal level activated partial thromboplastin time (APTT). Sixty-eight percent of children achieved a minimal level APTT by 24 h and 81% by 48 h. For all 65 children, APTT values were within the therapeutic range 43% of the time. APTT values outside the therapeutic range were twice as likely to be low as high. The average amount of heparin required to maintain therapeutic APTT values for children was 22 U/kg/h: 28 U/kg/h for infants < 1 y and 20 U/kg/h for the rest. Bleeding was rare (2%) and mild. Documented recurrent thrombotic disease was more common (7%) with associated morbidity.(ABSTRACT TRUNCATED AT 250 WORDS)

Phase I clinical and pharmacokinetic study of menogaril (7-con-O-methylnogarol) in previously treated patients with acute leukemia

Fifteen patients with relapsed or refractory acute leukemia were treated in this phase I study of menogaril (7-con-O-methylnogarol), a nogalamycin anthracycline derivative. Doses ranged from 50 mg/m2/day to 130 mg/m2/day, administered daily for 5 days. Pharmacokinetic studies were performed at each dose level and confirmed the findings of pharmacokinetic data derived from previous studies in patients with solid tumors. All patients experienced grade 4 hematologic toxicity and the dose limiting toxicity was mucositis. Two patients, one with acute myeloid leukemia and one with acute lymphoid leukemia, achieved complete responses. The AML complete response lasted 10 months and the ALL patient died in CR at 2+ months. Both patients were treated at a dose of 100 mg/m2/day for five days. At this dose, a second induction or consolidation course could be given without severe mucositis, and this is the dose recommended for further phase II studies in leukemia using this schedule.

Long-term follow-up of treatment and potential cure of adult acute lymphocytic leukemia with MOAD: a non-anthracycline containing regimen

A total of 55 previously untreated adults with acute lymphocytic leukemia (ALL), median age 38 years (range 15-73 years), were treated with MOAD (methotrexate, vincristine, L-asparaginase, and dexamethasone). This regimen includes five phases--induction, consolidation, cytoreduction, maintenance, and central nervous system (CNS) prophylaxis with parenteral high-dose methotrexate. Of the 55 evaluable patients, 42 achieved complete remission 76%), with a median CR duration of 12+ months (range 0.5-195+ months). The median survival in remission is 22+ months (range 1-198+ months), with 33% of remitters continuing in long-term remissions (> 5 years). Two out of four patients who developed CNS leukemia did so without marrow relapse, were successfully treated for that complication, and continue in total complete remission at 8+ and 16+ years. Another patient with extramedullary relapse (breast) was treated with radiation to that site and remains in total CR at 16+ years. Expected toxicities included myelosuppression during the induction phase of treatment, with 65% of patients requiring intravenous antibiotics. Mucositis was the next most frequent toxicity and required dose-reduction in seven patients. Minimal toxicity was seen during the post-remission phases of treatment. L-Asparaginase toxicity was more prominent during intravenous administration (24 patients) than when the intramuscular route of administration (30 patients) was used. The remission rate and long-term survivorship achieved with this regimen, without the use of an anthracycline, is comparable to that of other regimens for adult ALL. MOAD was well-tolerated by young and old adults with ALL. Aseptic necrosis of bone, successfully treated in each instance, occurred in four long-term disease-free survivors. The effect of this complication and its treatment on quality of life has been negligible.

Tumour-like localized amyloid of the brain is derived from immunoglobulin light chain

A patient is presented in whom the amyloid component of an intracerebral 'amyloidoma' has been purified and characterized by amino acid sequence analysis. The material originated from an autopsy of a 76-year-old man who 15 years earlier had been operated for an intracerebral 'amyloid tumour'. The tumour had recurred and grown to an almost walnut-sized mass in the right cerebral hemisphere. It was located in the parietal lobe close to the lateral ventricle and had a close connection to the choroid plexus. Histological examination showed large masses of amyloid surrounded by some plasma cells and a few macrophages of the foreign body type. Amino acid sequence analysis of a major fibril subunit protein showed homology with the variable region of a monoclonal lambda immunoglobulin light chain, subgroup III or IV. This shows that the amyloid in the 'tumour' was of AL type and presumably derived from local synthesis by plasma cells.

The prevalence of occupational injuries in EMTs in New England

OBJECTIVE

To characterize the prevalence and morbidity of injuries to emergency medical technicians EMTs) in New England [United States].

DESIGN

A survey was mailed to a 2% random sample of all registered EMTs in the six New England States. The identity of the EMTs remained anonymous, and a second mailing was used to improve return rate. The EMTs were requested to recall events that occurred during the previous six months.

RESULTS

A total of 439 of the 786 (56%) surveys were returned representing 13,875 hours of duty time in the six-month period. Seventy-one percent of the EMTs were male with a mean age of 35 years. Sixty-six percent were basic-EMTs. Injury attack rates (number of injuries/100 EMTs/6 months) were: stress, 11.2; back, 10.5; extremity, 9.8; assault, 8.4; ambulance collision, 4.1; hearing loss, 2.5; and eye injury, 1.4. Twelve percent of the EMTs were injured more than once in the six-month period. The paramedics more frequently were involved in ambulance collisions, suffered from stress, and were less likely to injure their back. There were minor interstate differences. Disability due to back injury affected 2.5% of those surveyed, four EMTs lost duty time secondary to an assault, and 0.5% of the EMTs were out of work due to stress.

CONCLUSIONS

This survey begins to characterize the occupational risks of EMTs. The prevalence of back injuries, assault, stress, and extremity injuries seems to be too high. Educational programs and preventive interventions should be designed to minimize back injuries, stress, and assault. There is a need for more research nationwide in order to better characterize these injuries.

A phase II trial of CI-921 in advanced malignancies

CI-921, (9-[[2-methoxy-4-[(methylsulfonyl)amino]phenyl]amino]- N,5-dimethyl-4-acridinecarboxamide 2-hydroxyethanesulfonate (1:1)), an anilinoacridine derivative with activity in experimental solid tumors was studied in a multicenter phase II trial in patients with solid tumors. Eligible tumor types included cancers of the breast, stomach, pancreas, nonsmall cell lung, small cell lung, colon, head and neck area, and melanoma. Prestudy requirements included an ECOG performance status of < or = 2, no CNS metastases, and measurable disease. CI-921 was administered intravenously over 1-2 hours on days 1, 8, and 15 of a 35-day course at an initial dose of 270 mg/M2, with modification in subsequent courses based upon tolerance. Principal toxicities included leukopenia, marked phlebitis, and mild nausea and vomiting. One hundred fifty patients were entered of whom 132 were evaluable for response. There was one complete and one partial response among 19 patients with breast cancer, and two partial responses, one each among 14 head and neck and 36 nonsmall cell lung cancer patients.

Percutaneous pericardial catheter drainage in childhood

The clinical course of 41 consecutive pediatric patients (mean age 7.6 +/- 5.8 years, weight 27 +/- 22 kg) who underwent percutaneous pericardial drain placement during a 3-year period were reviewed. The most common diagnoses were malignancy (20%), postpericardiotomy syndrome (17%), aseptic pericarditis (12%), and patients recovering from a Fontan type of operation (12%). Indications for drainage included increasing effusion size determined by 2-dimensional echocardiogram (48%), clinical deterioration (33%) and echocardiographic evidence of hemodynamic compromise (12%). Only 3 (7%) patients had clinical evidence of cardiac tamponade. Drainage catheter placement was accomplished percutaneously from the subxiphoid approach. Insertion was successful in all but 1 patient (98%) and successful evacuation of the pericardial space was achieved in 93% of patients. There was 1 death in a critically ill 2-week-old infant and 4 complications, 3 of which occurred in patients aged less than 2 years. Drainage catheters remained in position from 1 to 18 days (mean 3 +/- 3 days) with no late complications. There were 3 instances (7%) of drainage catheter occlusion. These data support the notion that placement of a percutaneous pericardial catheter is safe and effective in providing definitive drainage of the pericardial space in the pediatric age group. Children younger than age 2 years may be at increased risk for complications.

Ambulatory blood pressure monitoring and left ventricular mass and function after successful surgical repair of coarctation of the aorta

Late cardiovascular morbidity and mortality remain significant despite apparently successful surgical repair of aortic coarctation. Alterations in cardiac function have been reported in normotensive patients who have had successful repair, the reasons for which remain unclear. This study addresses the relation between ambulatory blood pressure measurements and alterations in left ventricular performance in 20 patients with normotension at rest after successful repair of aortic coarctation. Exercise testing, ambulatory blood pressure monitoring and two-dimensional echocardiographic studies in 13 boys and 7 girls (mean age 14.2 +/- 2.31 and 14.7 +/- 3 years, respectively) who had no evidence of recoarctation were compared with the findings in 20 matched control subjects. No difference was found in systolic blood pressure at rest or peak exercise between patients and control subjects. Male patients developed a significant arm/leg gradient at peak exercise. Systolic ambulatory blood pressure was higher throughout the day in the male group. In the female group, systolic blood pressure was higher only during sleep. No difference was found in diastolic blood pressure or heart rate. The transverse aortic arch was smaller and the left ventricular mass greater in all patients. The relation of wall stress to rate-corrected velocity of shortening was 2 SD above normal in 8 of the 20 patients, suggesting that some have enhanced contractility. The E/A ratio on the atrial echocardiogram was significantly reduced in the patient group. Successfully treated patients who are normotensive at rest after operation are still at risk for developing end organ damage, which is probably explained by incipient mild hypertension documented by ambulatory blood pressure monitoring.

Balloon atrial septostomy under transesophageal echocardiographic guidance

Balloon atrial septostomy is an established method of palliation for several forms of congenital heart disease. Previously performed under fluoroscopic x-ray control, recent reports have demonstrated the utility of transthoracic echocardiographic monitoring. We report the first application of uniplane transesophageal echocardiography (TEE) (6.7-mm probe) as an alternative imaging modality for control of balloon atrial septostomy on neonates in the intensive care unit.

Guidelines for cardiac monitoring of children during and after anthracycline therapy: report of the Cardiology Committee of the Childrens Cancer Study Group

The anthracycline antibiotics, daunorubicin, doxorubicin, and the newer derivatives, are important components of many antineoplastic chemotherapeutic regimens. Their usefulness is limited by their cardiotoxicity. Sequential monitoring of cardiac function of patients undergoing chemotherapy allows identification of subclinical cardiotoxicity. In many patients monitoring can thus guide the modification of the chemotherapy to minimize cumulative cardiotoxicity, reducing acute and long-term clinical and subclinical sequelae. Such monitoring also aids in the comparison of cardiotoxicity produced by different drugs and different methods and schedules of drug administration. The considerable variability of monitoring regimens between institutions and in the literature has detracted from its usefulness. The Cardiology Committee of the Childrens Cancer Study Group has, therefore, reviewed the field and has formulated recommendations for standardized noninvasive monitoring of children during and immediately after chemotherapy and for the modification of the chemotherapy where indicated.

Obesity among Navajo adolescents. Relationship to dietary intake and blood pressure

We evaluated anthropometric measurements, blood pressures, dietary intakes, and self-perceived body image of 352 Navajo Indian adolescents. Thirty-three percent of the girls and 25% of the boys were obese according to a body mass index criterion. Navajo youth tended to have larger skinfolds than their white (National Health and Nutrition Examination Survey II) and Mexican American (Hispanic Health and Nutrition Examination Survey) counterparts, with the greater difference in the subscapular skinfolds indicating a greater amount of truncal rather than peripheral fat. When divided into lower, middle, and upper thirds of body mass index, systolic and diastolic blood pressures were positively related with increasing body mass index for girls, and systolic blood pressure and body mass index were related among boys. The high prevalence of obese adolescents and the apparent effect of the increased weight on blood pressure in this population indicate the need for interventions aimed at improving dietary habits and fitness levels.

Factors influencing the persistence of shunting within 24 hours of catheter occlusion of the ductus arteriosus

Catheter occlusion of the persistent ductus arteriosus recently became clinically available with a Rashkind (USCI Bellerica, Massachusetts, USA) umbrella occluder system. A few patients, however, had residual left to right shunting after the procedure. The impact of soaking the foam of the device in a thrombin solution to enhance clotting and of using a device with a diameter of 12 or 17 mm was assessed in 117 consecutive patients undergoing catheter closure. The frequency of residual shunting detected by colour flow Doppler 24 hours after the procedure was the same whether or not thrombin was used.